Therapy following Botulinum Toxin Injections

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Therapy following Botulinum Toxin Injections
Jenny Lewis Senior Physiotherapist Kylie
Aroyan Senior Occupational Therapist Ruth
Evans Senior Occupational Therapist Rehabilitati
on Department The Childrens Hospital at Westmead
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Presentation Outline

• What is cerebral palsy?
• Physical components of cerebral palsy
• Spasticity (Stiffness)
• Movement problems
• weakness
• Medical Treatments
• Botulinum Toxin (BTX)
• Therapy Interventions after BTX
• 3 Case Studies Research into Practice

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What is cerebral palsy?

• Group of disorders problems with development of
  movement and posture
• Causes activity limitations
• Attributed to non-progressive disturbances in the
  developing fetal or infant brain.
• The movement disorders of cerebral palsy are
  often accompanied by disturbances of
• sensation, cognition, communication, perception
  and/or behaviour, and/or by a seizure disorder.
• (Bax et al, 2005)

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How common is cerebral palsy?

• Most common childhood disability
• World wide incidence estimated as 2 to 2.5 in
  1000 live births
• MRI can determine gestational age at insult
  (Ashwal et al, 2004)
• Cerebral Palsy can affect whole body, or one side
  or legs only

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Cerebral Palsy affecting upper limb
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Cerebral Palsy affecting predominantly lower limbs
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Physical Aspects of CP Spasticity

• Spasticity
• muscle stiffness
• result of brain sending less inhibitory signals
  to a muscle
• is abnormal and results from damage to brain or
  spinal cord.
• Velocity dependent resistance to passive
  stretch

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Spasticity
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Spasticity (Stiffness)

• Spasticity can cause
• pain
• difficulties with movement
• difficulties with care and hygiene
• Spasticity can help with
• muscle bulk
• standing up and sitting tall
• circulation

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Physical Aspects Weakness

• Weakness is often seen in CP
• In particular muscle groups
• Neurological basis
• Strengthening can improve the weakness, but not
  to normal levels.

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Physical Aspects Movement Problems

• Movement control is the ability to physically
  move body as desired
• Problems may include
• Slow
• Inaccurate
• Tremor
• Ataxia (uncoordinated movement)
• Involuntary movements (dystonia)
• We would estimate all children with CP have some
  movement control problem

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CP Other problems

• Approximately 50 use assistive devices (splints,
  wheelchairs)
• 70 have other disabilities
• Cognitive impairment hard to identify
• some relation to the physical severity of
  cerebral palsy
• If whole body afffected, more likely to have cog
  imp
• If hemi, more likely to have normal IQ
• Epilepsy approx 43 (study of 1918 children)
• Vision Impairment 28
• Speech Language disorders 38
• Hearing Impairment 12
• (Ashwal et al, 2004)

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GMFCS level 1
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GMFCS level 2
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GMFCS Level 3
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GMFCS level 4
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GMFCS level 5
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MACS 1

• Handles objects easily
• Some difficulty with tasks requiring speed and
  accuracy.
• Independent in daily activities

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MACS 2

• Handles most objects reduced quality and speed.
• Alternative ways of performing
• Does not limit most activities of daily living

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MACS 3

• Handles objects with difficulty
• Performance slow and limited success
• Needs help to prepare and/or modify

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MACS 4

• Handles limited selection of objects with
  adaptations
• Requires continuous support for even partial
  achievement

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MACS 5

• Does not handle objects
• Severely limited ability

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Treatments for Cerebral Palsy

• No cure, no pre-birth test
• Medical treatments aim to reducing spasticity,
  correcting deformity, decreasing pain.
• Include injections, surgery and medication.
• Therapy treatments aim to increase independence
  and ease of care through activities, exercise,
  stretch and use of assistive devices.

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Medical Treatments Botulinum Toxin A

• BTX is a nerve toxin, purified from the toxin
  that causes Botulism.
• Not all muscles that are affected can be
  injected.
• BTX stops the nerve signals being able to get to
  the muscles
• The effect of BTX generally lasts 3-6 months
• BTX is given by injection into the muscles that
  are affected by spasticity

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Botulinum Toxin A (BTX-A)
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Injection Techniques

• EMLA cream
• Nitrous oxide sedation
• Muscle localisation confirmed with electrical
  stimulation in upper limb and some lower limb
  muscles

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Practical Aspects of BTX-A

• Used since the 1990s for children with cerebral
  palsy.
• Generally require multiple injection sites for
  leg muscles to ensure adequate spread of BTX.
• Children may have up to 16 injections per
  session.
• Cost up to 1000 per child per set of injections
  
• The cost of BTX-A is reimbursed by the government
  for some injection sites (legs only).

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Side Effects of BTX-A

• Current medical research and opinion article
  published in 2004 no major systemic side
  effects, minor side effects related to injection
  site (bruising, focal weakness).
• Our experience at CHW some related to procedure
  (nausea, vomiting, bruising, pain at injection
  site), some related to medication (very low
  incidence of incontinence, and weakness)

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Hamstring Muscle Injection
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Botulinum Toxin Child Selection

• Steps in selecting a child for BTX
• Child must have spasticity
• 2. Child must have goals that could be achieved
  if the effect of the spasticity is removed
• There must be research and/or clinical experience
  that justifies the use of BTX in that child
• Follow up therapy is available

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Therapy after BTX-A injections

• Goal For improved function and/or independence
• Stretching
• Strengthening
• Retraining

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Therapy after BTX-A injections

• Goal For increased ease of care
• Positioning
• Splinting

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Physiotherapy after BTX-AResearch

• To date there is very limited objective evidence
  to support or refute use of therapy after BTX-A
  injections (Lannin et al, 2006).
• Research has looked at lower limb serial casting
  /- orthotics, and physio after botox eg
  exercises, electrical stimulation (Boyd et al,
  2000 Detrembleur, 2002 Molenaers et al, 1999)
• Further research is being conducted

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BTX-A Role of the physiotherapist

• Use BTX-A to achieve goals.
• Serial casting for contracture management-
  increase range of motion
• Home/school program eg standing, positioning
• Stretching and strengthening
• Functional retraining (gait)
• Orthotics

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Physiotherapy after BTX-AIn practise
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Occupational Therapy After BTX-A Research

• Research is still emerging in this field.
• To date there is very limited objective evidence
  to support or refute use of therapy after BTX-A
  injections (Lannin et al, 2006).
• Very recent studies now suggest that OT for
  children with cerebral palsy improves quality of
  movement, function and spasticity. The functional
  gains can be maintained (Lowe et al, 2006).

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Occupational Therapy after BTX-AIn practice

• Dependent on child family goals level of
  severity
• Casting and splinting to stretch shortened
  muscles to enable better biomechanical alignment
• Splinting and task adaptations to encourage
  success at tasks
• Active strengthening and stretching through use
• Retraining in tasks bi-manual training or
  constraint induced therapy (varying styles of
  constraint)

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Occupational Therapy
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Occupational Therapy
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Occupational Therapy
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Occupational Therapy
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3 Case Studies

• 3 children with spasticity, causing 3 different
• problems
• A child who cant lift up their hand to help hold
  something (OT)
• A child whose legs cross when walking and sitting
  (PT and OT)
• A child who walks on their toes (PT)

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Case Studies
1. What do we want to achieve? 2. What does the
research prove? 3. What does clinical experience
show us? 4. What do we do in practice?
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Case Study 1 Upper Limb BTX-A

• 5 year old boy with CP who has difficulty
  reaching for an object
• Goal
• increase ease of reaching
• better hand placement for grasp
• Bonus better grasp of object
• Can Botulinum Toxin assist to achieve this?

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Case Study 1
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BTX-A injections OT provide significant
improvements in UL function

• Length of treatment effect
• For 1 month (Fehlings et al 2002)
• For 3 months (Yang et al, 1999)
• Sustained at 6 months (Lowe et al, 2006)
• For at least 9 months (Speth et al, 2005)
• The upper limb functional outcomes are
• Functional improvements are sustained after BTX
  has worn off (Wallen et al, 2004)
• Fine motor skills (Yang et al, 1999)
• Quality of movement (Lowe et al, 2006)
• Range at elbow (Wallen et al, 2004)

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Case Study Outcome Upper Limb BTX OT

• Outcome of case study
• Can reach more easily for objects
• Hand placement improved
• Grasp still weak

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Case study 1

• Clinical practice
• Children who present with limitations in
• reaching skills, whose goal is to increase
• function, are offered Botulinum Toxin
• injections

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Case Study 2 Joint OT and PT

• 4 year old boy with CP whose legs scissor
• (adduct) when walking
• Goal
• to decrease scissoring when walking
• to enable him to sit cross-legged
• independently
• Can Botulinum Toxin assist to achieve this?

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Case Study 2
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BTX-A into adductor muscle improves walking
sitting

• Significant improvement in gross motor
  function
• - 1 month following BTX injection (Mall et al
  2000)
• - 3 months after injection with BTX (Yang
  et al 1999)
• - 12 months after injection (however this study
  had no
• comparison group) (Linder et al 2001)
• Parents reported improvement in quality of
• walking 3-4 months following BTX injection to
  the adductor
• muscles (Heinen et al 1999)
• More comfortable sitting position enabling
  increased
• participation in activities (Heinen et al
  1999)

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Case Study Outcome

• Outcome of case study
• Less scissoring when walking
• Increased ease of getting into cross
• legged sitting with assistance
• Able to maintain cross legged sitting
• independently

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Case Study 2
Clinical Practice Children who present with
scissoring due to spasticity, whose goal is to
increase function, are offered Botulinum Toxin
injections
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Case Study 3 Lower Limb BTX-A

• 3 year old boy with spasticity who walks on
• his toes
• Goal
• - to enable him to walk with feet flat
• Can Botulinum Toxin assist to achieve this?

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Case Study 3
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BTX-A injections PT improves gait
Significant improvement in walking quality
- 1 month following BTX injection to the
calves (Galli et al 2001,
Dunsun et al 2002) - up to 2 years following
repeated injections with BTX to the calves (Koman
et al 2001)
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Case Study Outcome

• Child walks with feet flatter and is more able
• to tolerate ankle splints

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Case Study 3
Clinical Practice Children who present with
walking on their toes due to spasticity, whose
goal is to improve walking pattern, are offered
Botulinum Toxin injections
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Summary

• CP is common
• BTX-A is a common treatment
• BTX-A combined with therapy at home and at
  preschool makes significant improvements in
  functional abilities
• PRACTICE, PRACTICE, PRACTICE!!

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Contacting Us

• Rehabilitation Department Ph 9845 2819
• Jennifr5_at_chw.edu.au
• KylieA_at_chw.edu.au
• Ruthe2_at_chw.edu.au

Thanks to the Children and Families of the PDC
service at CHW CP PDC team ROCC team Rehab
Department at CHW
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References

• Ashwal S, Russman BS, Blasco PA, Miller G,
  Sandler A, Shevell M, Stevenson R (2004).
  Practice parameter Diagnostic assessment of the
  child with cerebral palsy. Neurology 62(6), 23
  March 2004, pp 851-863.
• Bax M. Goldstein M. Rosenbaum P. Leviton A.
  Paneth N. Dan B. Jacobsson B. Damiano D. (2005).
  Executive Committee for the Definition of
  Cerebral Palsy. Proposed definition and
  classification of cerebral palsy, April 2005.
  Developmental Medicine Child Neurology
  47(8)571-6.
• Graham K et al. (2000). Recommendations for the
  use of botulinum toxin type A in management of
  cerebral palsy. Gait and posture. 11 67-79.
• Hoare B, Imms C (2004). Upper-limb injections of
  botulinum toxin-A in children with cerebral
  palsy a critical review of the literature and
  clinical implications for occupational
  therapists. American Journal of Occupational
  Therapy Jul-Aug 58(4) 389-397.
• Boyd R et al (2000). Biomechanical transformation
  of the gatsroc-soleus muscle with botulinum toxin
  A in children with cerebral palsy. Developmental
  Medicine and child neurology 42(1)32-41

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References

• Heinen F, Linder M, Mall V, Kirschner J
  Korinthenberg R. (1999). Adductor muscle
  spasticity in children with cerebral palsy and
  treatment with botulinum toxin type A A parents
  view of functional outcome. European Journal of
  Neurology. 6 47-50
• Law S, Leffers P, Janssen-Potten Y, Vles J.
  (2005). Botulinum toxin A and upper limb
  functional skills in hemiparetic cerebral palsy
  A randomised trial in children receiving
  intensive therapy. Developmental Medicine Child
  Neurology, 47 468-473
• Lannin N, Scheinberg A, Clark K. (2006). AACPDM
  systematic review of the effectiveness of therapy
  for children with cerebral palsy after botulinum
  toxin A injections. Developmental medicine and
  child neurology 2006 48 533-539.
• Lowe K, Noval, I Cusick A. (2006).
  Low-dose/high concentration localised botulinum
  toxin A improves upper limb movement and function
  in children with hemiplegic cerebral palsy.
  Developmental Medicine Child Neurology. 48
  170-175.

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References

• Mall et al (2000). Evaluation of botulinum toxin
  A therapy in children with adductor spasm by
  gross motor function measure. J Child Neurology
  2000 15214-217
• Reeuwijk A, Van Schie P, Becher J Kwakkel G.
  (2006). Effects of botulinum toxin type A on
  upper limb function in children with cerebral
  palsy a systematic review. Clinical
  Rehabilitation. 20 375-387.
• Wallen M, OFlaherty S Waugh MC. (2004).
  Functional outcomes of intramuscular botulinum
  toxin type A in the upper limbs of children with
  cerebral palsy A phase II trial. Arch Phys Med
  Rehab. 85 192-200.
• Galli M, Crivellini M, Santambrogio E, Motta F.
  (2001).Short-term effects of botulinum toxin A as
  treatment for children with cerebral palsy
  Kinematic and Kinetic aspects at the ankle joint.
  Functional Neurology 16317-323

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Websites

• www.wemove.org
• www.ipsen.ltd.uk/products/dysport
• www.chw.edu.au/rehabilitation
• http//www.medtronic.com/neuro/spasticity/
• http//www.thespasticcentre.org.au/index.htm
• www.fhs.mcmaster.ca/canchild